NIGERIAN CIVIL AVIATION AUTHO Corporate Heaclquarters: Naam Azikwe Intemational Aiport, Domestic Wing, Abuja Tel: +234 811 115 0990, +234 811 115 113 Ref: NCAA/DAWS/AD.1127/VOL.7/067 1% August 2023 ‘The Accountable Manager Max Air Ltd, 16 Ashton Road, Kano State. Attn: Safety & Quality Manager MAX AIR SPOT AUDIT Refer to the Authority's letter with reference number NCAA/DG/AIR/11/16/363 dated 12% July 2023. Spot audit of your organization was carried out at Max Air’ s facility in Kano from 17% July 2023, till 20 July 2023, and several deficiencies were noted. These deficiencies were brought to the attention of your organization during the audit debrief. Find attached the Summary of Findings Form (Form: AC-AWS023A) containing the airworthiness related findings noted during the audit. Also attached Is Appendix A containing detailed list of these findings in addition to those not captured in the summary Form. Max Air Ltd is required to review these findings, identify their root causes; develop, and implement immediate corrective action plans to not only close these findings but also mitigate their reoccurrence. Evidence of rectification of these findings must be submitted to the Authority within the indicated time limits, Please, be guided accordingly fam Engr. 1A. NWABUDIKE Aviation Safety Inspector For: Director-General - Abuja Begional Office: +234 811115 3888; Lagos Regional Office: ~234 (1)2780421, +234 (1) 2780432; Kaduna Regional Office: +734 807 776 8881 Kano Regional Office: +234 815-555 6642; Port Harcourt Regional Office: ~234 705 923 3510. NCAA Call Center: +234 (1) 2790438; Emall:info@acazgorng | Website: www.ncaa.goungi Air presented some altered records to the Authority and failed to replace some ponents that have been due for replacement on a sampled aircraft. For instance, the sta dime components submitted by Max Air to the Authority during C of A renewal of SI ‘in 2022 includes this information: 2. That the last hydrostatic test (HST) on a Cargo fire Extinguisher with P/N 34200409-4 af ‘S/N 05111 was indicated as last carried out on 30” June 2013, and that it would become due on 30” June 2023. The hard time components list submitted to the Authority during the present audit now contains a different information that the last HTS on same component was last carried out on 30" June 2024, and that it would now become due on’ 30" June 2024. The operator has failed to produce documents, including the Form 1/8130: relating to the last HST carried out on these components. That the last HST on an APU Squib with P/N M30803828 and S/N 3090828 was last carried out on 30" June 2013, and that it would become due on 30” June 2023. The hard time: components list submitted to the Authority during the present audit now contain different information that the last HTS on same component was last carried out on 30" June 2014 and would now become due on 30" June 2024. The operator has failed to produce documents, including the Form 1/8130, relating to the last HST carried out on these components. That the last HST on a H,0 Fire Extinguisher (Portable) with P/N 892480 and S/N 2533A was indicated as last carried out on 31” January 2018, and that it would become due on: 30" January 2023. The hard time components list submitted to the Authority during the: present audit now contains a different information that the last HTS on same component was last carried out on 31" January 2019, and that it would now become due on 30” June 2024, The operator has failed to produce documents, including the Form 1/8130, relati to the last HST carried out on these components. ‘in block 12 of the FAA Form HML 020223-51 dated 03 F3) firm conformity/condition/release to service”. Max Air has not been able to provide docume containing the source and operational history of this part, the total flight cycles and flight how accumulated from manufacture, the total flight cycles and calendar time accumulated from Its i overhaul which could help determine when it would become due for next overhaul. Despite these anomalies, Max Air proceeded to install the part on the aircraft and started tracking the next overhaul period to be 21,000FC/10yrs from 10” May 2023. In the same manner, the FAA Form 8130-3 (Airworthiness approval tag) for the RH MLG with S/N (MCO5834P2918 shows thatit was released after overhaul on 22 November 2014. Max Airalleges that this part was recently purchased from a vendor and that it has been on storage since its last overhaul in November 2014. For this reason, the operator indicated in the hard time components list for this part that the next overhaul would be 21,000FC/10Yrs from 10" May 2023 when they installed the component on the aircraft. Max Air has not been able to provide the Authority with relevant records to substantiate the claim that the part had been under storage since 2014, and that it had not been installed and operated on other airplanes since its last overhaul in 2014. Several incorrect maintenance practices were observed from the corrective actions taken by Max Air towards rectifying the birdstrike/FOD incident that occurred on SN-MBD Engine #11 on 3 July 2023. a. In the techlog page 0038007, a certifying staff with Max Air authorization number MAX 033 MTCE, made an entry “#1 engine intake lip replaced AW AMM 71-11-01/401, found ok’ following a dent that was found on the engine cowl intake lip. P/N of Lip replaced was indicated as 314A1010-10 and S/N was indicated as not applicable (N/A). The Part’s rubbery tag indicates that this part was removed from another aircraft SN-BDK. The accompanying Max Air “Non-Routine and Unit Change Record” indicates “replacement of #1 engine intake due dent” and description of parts replaced was, again, shown as intake lip with P/N 3141010-10 with S/N not applicable. However, a review of these entries revealed that: i, Part Number 31441010-10 is for an engine cowl assembly and not the lip. From 8737-300 Illustrated Parts Catalogue, the P/N for an engine lip corresponding to a cowl assembly P/N 314A1010-10 is 314A1020-1. il, The reference 71-11-01/401 is for removal of an engine cowl assembly an¢ not an engine lip. An engine lip removal and installation is a structural repair task that is beyond the authorization of the certifying staff and Max Air. iii. 5N-BDK is not a serviceable aircraft and does not presently have an airworthiness certificate. iv. If it is an engine cowl that was replaced and not an intake lip, then an intake lip must have a S/N. Page2x Air has not been able to identify the exact engine serial part was removed, and has not been able to provide. “engine records. Therefore, the part, currently, is not traceable. SN-MBD techiog page number 0038008 also shows that the same certifying st ‘engine fan blades #6 (P/N 1590M21POI, S/N G53974) #7 (P/N 15901 ‘MAE261990) and #15 (1590M21P01, S/N MAE26299C) in accordance with AMM 02/401 following the dent caused by the bird strike. The robbery tags and “I ‘and unit change records” indicate that these parts were also removed from unserviceable SN-MBD. Review of the maintenance practices shows the following: i. There was no indication that the fans were replaced in pairs as recommended in the AMM to prevent moments that could introduce engine imbalance. Even when pairs of blades were not available, there was no evidence that the certifying staff performed the resulting tasks which includes, inter alia, ensuring that the opposite blades are not more than 50 grams-inch. Max Air has not been able to provide proof to the Authority that the fan blades can be traced to any specific engine S/N. Therefore, the operational history of the blades as well as their suitability to be installed on a serviceable aircraft have not been ascertained. 4) {it was discovered that some Max Air engineers perform maintenance tasks that they have not been trained and authorized to accomplish. For instance, ‘a, Max Air work Order No, MBD-8A-0139-2 indicates that a certifying staff with Authorization number MAX 04 performed an engine ground run on 15" Feb 2023 following an engine #1 replacement on SN-MBD. This personnel’s Authorization certificate shows that he is not authorized to perform Engine Ground Run. )._Max Air work Order No. MBD-8A-0140-2 shows that a certifying staff with Authorization number MAX 40 performed an engine ground run on 15" Feb 2023 following an engine #2 replacement on SN-MBD. This personnel’s Authorization certificate shows that he Is not authorized to perform Engine Ground Run. Max Air work Order No. MHM-RC-0223-0013-3 shows that a certifying staff Authorization number MAX 03 performed an engine ground run on 11" Feb following an engine #2 replacement on SN-MHM. This personnel’s Autho cettificate shows that he is not authorized to perform Engine Ground Run. Page 0038725 for SN-MHM indicates that a certifying staff with Aut er MAX 12 performed engine ground run following replacementduct overheat switch on 11" July 2023. ‘that he Is not authorized to perform Engine accomplishment of some critical tasks. For instance: ‘Max Air Work Order No. MHM-RC-0223-0013-2 shows that on 11” Feb 2023, a ce staff with Authorization number MAX 03 performed installation of engine #2 on’ A duplicate inspection by appropriately qualified personnel was not performed. Following the incident involving water in the fuel tanks of SN-MHM, an aircraft techlog Ie entry (ATL 0038721) shows that both the engine # 1 and #2 engine fuel filters as the APU fuel filters were replaced by the same certifying staff (with Authorization numb MAX 033). This is a critical task that should have been identified as a Required Inspectio Item (Ril) requiring duplicate inspection by appropriately qualified personnel. 6) Max Air carries out maintenance tasks beyond the scope approved by the Authority in the ‘operator's AOC Operations Specifications for Equivalent System. For instance: @. According to Max Air Work Order No. MHM-LMVV8-0057, it wes indicated that a Max Air NOT personnel with Authorization number MAX 037 accomplished AD 1999-10-12 requiring Ultrasonic inspection method whereas Max Air is not authorized to perform ultrasonic NOT inspections. This was carried out on 4"" May 2023. ._ In the AD-SB Tally Sheet for LMV8- check carried out on SN-MHM on 4" May 2023, same: NOT personnel with Authorization number MAX 37 accomplished the NDT inspection ‘option for AD 2020-26-09 that require both Eddy current and Ultrasonic NDT inspection to be performed at the center wing box. According to SN-MBD tech log page number 0037696, the same Max Air NDT personnel with Authorization number MAX 037 performed ultrasonic Inspection on main land ear of SN-MBD on 17” May 2023 following the burst tyre incident that had occurred © 7” May 2023, (STCs) were embodied on the aircraft as declared by the tor. Also, four (4) additional modifications were embodied on tl to Max Air. Most of these modifications contain Instids for maintenance accomplis tasks were being tracked and acco not demonstrated efficient management of the Airwo o the B737 aircraft fleet to ensure that all applicable tasks are ide: d as and when due. For instance: @. AD 2001-10-14: In the AD listing for SN-MHM and 5N-MBD, the AD was ii ‘accomplished on 19" December 2000 and 1" October 2014 respectively, and have been terminated (i.e to say that they would not been repeated). On the this AD is repetitive after the initial accomplishment. It is to be accomplished any tir ‘oxygen generator is replaced on the airplane. AD 2011-24-12 and 2023-10-12: These ADs were declared as “Not Applicable” to S5N-MBD and SN-MHM, and the reason cited was that the aircraft are equipped with R Altimeter. This is incortect because the ADs were developed to address potential issues: that may occur on Radio Altimeters installed on airplanes due to the 5G network. AD 2011-24-12: This AD requires that after accomplishment of the initial task, the repetitive interval which are step size based are either 1800 FC or SOOFC. in the AD. compliance list submitted for SN-MHM where the initial AD was accomplished since Feb 2013 (at 43,498 FC as obtained from previous records of aperator), Max Air indicated the repeat interval of the AD as 25,000FC. Based on the current FC of the aircraft which is above 56,000FC, this AD should have been repeated several times. 9) In Max Air, evaluation of Airworthiness Directives (ADs) and Service Bulletins (SBs) to determine their applicability and the specific tasks to be accomplished are caried out only by a Max Al Planning Officer instead of a team of qualified technical staff. The qualifications and aptitude of Max Air NOT personnel (two persons), who perform NDT inspections on Max Air aircraft and Wheels, were not found to be satisfactory. This is predice ‘on the following: @. Ado Musa Kofar Mata (who is also Max Air Workshop Manager) with Number MAX 030: i. His recent NDT training certificates were issued by GMF AeroAsia (I Indonesia). The certificate did NOT indicate the NOT training standard (E! 410 or EN ISO 9712, EN 473) that the course satisfies its requiret 7 indicate any Max Air “Written Practice” to which the training is be “indicate any national or international body that may have NOT training organization. Also, these certificates, which w three (3) NDT methods he practices, only show.the 24 hours classroom and passed the written exan attest to his completion of Specific and Practical examin: ‘required for initial certification” (BS EN 4179:2017]. “He does not have any certificate from a recognized health organization to ‘he passed the annual “Near Vision test’, and the “Colour Perception test” ‘conducted every five years — both of which must meet the requirements of ISO. (Non-Destructive Testing — Evaluation of Vision Acuity of NOT Personnel). In during the audit, he boldly informed the Authority that his vision is stl good and so. ‘there has never been a need for him to go for a vision test. This further supports the fact that his NDT training is very deficient since every NDT personnel trained and certified in accordance with a recognized standard knows that the expiration of any of the two vision tests certificate automatically nullifies the NDT certification that may have been held. When he demonstrated how aircraft wheels are built, he never consulted Max Air's procedures manual and the OEM Component Maintenance Manual (CMM) that is specific to an aircraft wheel. iv. While demonstrating how a Nortec 600 Eddy Current Flaw Detector isused to detect cracks, he made a statement that the equipment can be used to carry out Ultrasonic Inspection by simply changing the probes used. This statement cannot be supported and is considered incorrect considering the differences in working principle of Eddy Current and Ultrasonic NOT methods. All references/publications made in the technical specifications of Nortec 600 Eddy Current Flaw Detector by Olympus, the equipment manufacturer, never alluded to the possibilty of using the equipment for any other NDT method. b. Akingbehin Olusola Peter (with Authorization number MAX 037). i. _ His NOT training certificate (for Eddy Current and Penetrant Inspection methods only) was issued by a recognized NDT training organization in 2018 when he wes an ‘employee of Aero Contractors. The training was based on EN 4179 and NAS 410 Standards. However, the training certificate clearly shows that it was conducted based on AeroContractor’s Written Practice. When personnel leave the ‘employment of the organization under which his training is based, it becomes: nullified and cannot be transferred to another organization [ Par 8.3.3 of BS & 4179:2017). He has not done any NDT training under Max Air's Written Practice. Note: Max Air has not developed a Written Practice He also does not have any eye vision examination certification. Despite having not previously received any formalized training on UI n {considering that no Ultrasonic NOT training certificate coufecord with Max Air), and the absence of documented ce the General, Specific and Practical Examination requirements for method, he has been signing out tasks requiring the use of ultrasonic m is further compounded by the fact that Max Air is not authorized Ultrasonic NDT method under its AOC Operations Specifications, After evaluation of the list of Max Air’s tools and equipment, including si the certificates of all NOT tools and equipment held at Max Air workshop, it ‘observed that Max Air does not have any ultrasonic transducer positioner. This important because a sample review of one of the ultrasonic NDT tasks Mr. Peter performed (AD 1999-10-12) shows that two specific ultrasonic transducer positioners are required to accomplish the task. The Workshop Manager, when interrogated, confirmed that Max Air does not have any positioner. He also signed out tasks requiring the use of Magnetic Particle NDT inspection method on aircraft wheel bolts even though Max Air has not provided evidence to show that he has received any formalized training and certification on this NDT method. Evidence: Max Air “Main Wheel Assembly Workshop Traveller” ref no 2023/02/09/381 dated February 9”,2023 for aB737 Main Wheel Assy P/N 2606671- 2, S/N B5214/BH2085. 11) Several inconsistencies were observed in the NCAA Form 1 and supporting document titled “Workshop Traveller” that is issued from Max Air workshop after every wheel-tyre assembly. For instance: 2. NCAA Form 1 issued on 20/06/2022 under work order MAX/737/NW/22-06-20-158 for 8737 nose wheel assembly P/N 2607825-1, S/N B-3012/B-3012 made reference to 14CFR 43-9 as basis for the return to service instead of the Nig.CARs. It also references the procedure followed to be CMM 32-40-01 Rev 12 dated 22-07-2017. The supporting document called “Nose Wheel Assembly Workshop Traveller” references a different CMM 32-40-10 Rev 22 dated 5" May 2017. The correct reference for this nose wheel P/N is CMM 32-40-10 Rev 11 dated 20 May 2019. NCAA Form 2 Issued on 09/05/2023 under work order MAX/737/MW/23-05-03-432 (or 8737 main wheel assembly P/N 2606671-2, S/N B-10080/8-10080 also references 43-9 as basis for the return to service instead of the Nig.CARs. It also references th procedure followed to be CMM 32-45-02 Rev 12 dated 22-07-2017. The correct refer for this main wheel P/N is CMM 32-40-09 Rev 16 dated 6" August 2012 | the Nose and main wheel Form 1 evaluated, the 14CFR 43-9 and wrong |. in adcition, none of these documents references SPM 32-49-01 which ie procedures for carrying out NDT inspection on the wheels and bolts. if consulted the relevant CMM while performing their tasks, they would f °M 32-49-01. Honeywell made a strong recommendation in SPM.inspecting the wheels is the automatic type using. ‘carried out by an organization that has not been accredited by th on body in Nigeria. For example, the Eddy Current Flaw Detector Model 10176109; and Ultrasonic Flaw detector Model EPOCH 650 S/N 211356110 were cz nimateéc Nigeria Ltd on 29" September 2022 and 26” January 2023 respectively. As at th ‘of audit, Gammatec Nigeria Ltd was not found in the list of organizations accredited by the ia National Accreditation System (NiNAS). Gammatec has also not been audited by Max department and was not listed in Max Air’s 2022 and 2023 Audit Plan. Nitrogen cylinders found at the tyre store were without any identification tags. Therefore, there was no way to determine the source of the Nitrogen used by Max Air to inflate its aircraft tyres. Even though the tyre store officer explained that the cylinders were supplied by Mr. Shotayo of Showbrothers Ltd, Max Air has not provided copy of any agreement with this company and has not carried out audit on them to determine the quality of Nitrogen supplied. It is worth noting that inflation of aircraft tyres with nitrogen that contains more than 5% of oxygen have been attributed to causing aircraft tyre explosions. 414) Review of several technical log page (TLP) entries, tally sheets and task cards signed by several Max Air maintenance engineers seem to suggest that task cards were signed whereas not all the tasks were accomplished. For instance: a LMV3 maintenance task (300FH/40 days interval) comprising 27 LMV3 tasks, and other lower tasks (LMV 2 and LMV 1) were accomplished within a short period of time at the airport tarmac in Kano at night. Entries made in SN-MHM technical log pages from # 0022929 to #0022931 implies that all LMV3 tasks were completed between 23:55 on 27” June 2023 and 05:50am on 28" June 2023. Task 32-046-01 require that the nose and main landing gears be checked for proper inflation, and that record of the initial pressure values and the values obtained after 24hrs should be made. The obtained pressure values were not indicated but the task was signed out. Tsk 25-042-01 requires, among other things, that a pressure gage check on t ‘emergency escape slide be repeated after 24 hours. There was no evidence that this task was repeated after 24hrs. Yet the task was signed out on 28" June 2023 with statement that it was found satisfactory.b. Following the water that was found in the fuel tanks in Yola on 7" july 2023, part of the actions taken by the certifying staff (with Authorization number MAX 033 MTCE) was recorded in ATL #0038723. i. “Cleaning and inspection of the aircraft C/O I.A\W AMM 28-10-00-912-342". Part of the concluding part of this task require the accomplishment of another task 28-AWL- 28” CDCCL. There was no evidence or entry in the technical log that this task was accomplished. ji, “Application of Biobor carried out IAW AMM 28-11-00-622-028", This entry was made on 10" July 2023. According to AMM 28-11-00-622-028, the biocide treatment should soak per biobor JF soak time of 72 hours (3 days). After the soak time, “sump each tank to remove water". However, ATL # 0038724 dated 11" July 2023 shows that the aircraft was deployed for flight (Lagos to Abuja) carrying SO passengers without completing the treatment interval, 15) Following the aircraft #1wheel removal that occurred on 7" May 2023 during take-off on SN-MBD, and the subsequent explosion of the remaining #2 tyre during landing, it was observed that Max Air carried out Conditional inspection on the affected LH Main Landing gear without performing similar inspection on the RH main landing gear which had taken most of the aircraft load during landing. 16) Max Air could not provide records of some components presently installed on the aircraft or some components recently replaced on the aircraft. For instance, a. According to ATL # 0036062, there is a maintenance entry dated 10” May 2023 regarding replacement of escape slides with P/N 61620-468 and S/Ns 2354A and 0447A. Max Air technical records personnel could not find records of Form 1/Form 8130-3 for these two components recently removed. of the Oxygen Generators presently installed on SN-MHM could not be provided. Therefore, these components which are life limited are not being tracked to ensure that they are replaced as and when due. ¢. The list of all components installed on SN-MHM, which is dated 30” June 2023, isnot a reflection of the current components actually installed on the aircraft. This is because all the components that have long been replaced are still reflected in the list. 17) Max Air has not carried out audit of all its subcontractors including but not limited to the fuel suppliers, AMOs, ATOs, spare parts suppliers, equipment calibration laboratories, etc. Moreover, the 2022 and 2023 audit plans did not include all the subcontractors. For instance: Page 9 of 11Air uses the following organizations as its fuel suppliers: OVH, CITA, CYBERNETIC, GEOMETRICS, kerojet services, etc, in the various lo ‘operates into. However, only Nepal, 11plc, Total and Octavus were included in and 2023 audit plans by the Quality department. Octavus station in Abuja and Lagos are the only fuel suppliers that have been audited. itis important to note that Air does not have contract agreement with any of its fuel suppliers. In the same manner, Leadstream Aviation, which is one of the major ATOs that provides training for Max Air technical staff, was not listed in the present and past audit programs and have not been audited by Max Air Quality department. AeroConsult, which is also a major ATO used by the operator has not been audited even though it was listed in the audit pians. 118) |t was discovered that some of the fuel suppliers indicated on Max Air aircraft technical logs during fuel uplifts were not the actual fuelers that provide the fuel. In Kano, for instance, it was discovered that even though OCTAVUS receipt is issued to Max Air after fueling, the fuel bouser is from another organization called Goal energy. It was explained that OCTAVUS and Matrix supply fuel to Goal energy, while the later store the fuel, take responsibility for quality of fuel put in the bousers and supplies the fuel to the aircraft. Goal Energy is yet to obtain NCAA's approval as a fuel supplier. 19) The procedure for fueling and defueling Max Air aircraft fleet were not clearly delineated in the operator’s MCM. 20) Water check was not included in the checklist items for Max Air’s B737CL that are under MSG-3 even though it was listed under the MSG-2 checklist. 21) During the aucit, it was observed that Max Air does not have enough Planners and Technical Records personnel. The operator has only one Technical Records personnel while the duties of planning revolve around one individual even though Max Air had provided a list indicating that they have more than one Planner. 22) \t was discovered that some of the unscheduled maintenance tasks performed by Max Air engineers and contracted AMOs were not supported with Work Orders. Therefore, there were no clear instructions on what and how the task should be carried out. 23) \t was discovered that Max Air does not comply with its procedures for ensuring the effectiveness of the Aircraft Maintenance Program as contained in the approved Reliability Program. For instance, reliability reports are not generated; and meetings are not held to review non routine maintenance tasks generated during scheduled maintenance. iring the audit, it was discovered that some of the transit checks at some locations such and Yola were carried out by the Pilotin Command (PIC) and not by a certifyingMax Air has not provided any evidence that the pilot received appropriate trainings to perfor this level of check. 25) Even though Max Air’s Maintenance Training Manual contains procedures for ascertaining continued competency of engineers/technical staff, these procedures were not being implemented, 26) Max Air's 8737 MEL was found not to be up to date. The MEL is based on MMEL Rev 61 whereas the latest FAA issued MMEL revision, as at the time of the audit, is 62. 27) Max Air B737CL -MSG-2 AMP is not up to date. It has not been updated to the latest revision of the MPD (06-38278) dated 25" March 2023 (as at the time of the audit)